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461. Using Reported Primary Care Errors to Develop and Implement Patient Safety Interventions: A Report from the ASIPS Collaborative (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/West.pdf
     September 01, 2005 - • A process focus—ASIPS interventions were developed to address the processes within which errors occur … prevention orientation—ASIPS interventions focused upon reducing hazards and preventing errors before they occur … technique to be extremely useful for summarizing our onsite observations of how practice-level processes occur … information technology to reduce the frequency of errors and identify errors immediately when they occur … that individual was away from the practice, tracking of ordered and received test results did not occur

462. Facilitator Guide: Optimize Your Briefings and Debriefings (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/surgery/modules/implementation/imp_opt_briefings_facnotes.docx
     December 01, 2017 - They are an opportunity to LISTEN to the wisdom of your frontline providers as defects occur. … By default, they occur at the beginning of a case to ensure every member of the care team is on the same … Huddles occur on an emergent or as-needed basis. … Different sections can occur at different times. … Slide 26 Timeout: Prior to Incision SAY: A timeout can occur just before incision to verify the patient

463. From Here to There: Lessons from an Integrative Patient Safety Project in Rural Health Care Settings (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol1/Cook.pdf
     January 01, 2004 - Hoas, Katarina Guttmannova Abstract To date, few studies have focused on patient safety issues that occur … case studies, also e-mailed to team members, were based on the kinds of patient safety issues that occur … blameless way for health care providers to present and discuss patient safety issues that could—and did—occur … As a result, decisions about recognizing, reporting, and disclosing errors that occur in rural health

464. Final Progress Report: Electronic Clinical Surveillance To Measure and Improve Safety in Ambulatory Care (pdf file)
     www.ahrq.gov/sites/default/files/2024-12/danforth-report.pdf
     January 01, 2024 - have primarily focused on inpatient settings; however, an estimated one billion outpatient visits occur … Results: In outpatient settings, care gaps (or deviations from “ideal” care) occur regularly enough

465. Presentation: Optimize Your Briefings and Debriefings
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/surgery/modules/implementation/imp_opt_briefings.pptx
     December 01, 2017 - They are an opportunity to LISTEN to the wisdom of your frontline providers as defects occur. 2 Safety … By default, they occur at the beginning of a case to ensure every member of the care team is on the same … Huddles occur on an emergent or as-needed basis. … Brief, informal information exchange and feedback sessions Occur after an event or shift Stress learning … Different sections can occur at different times.

466. Hypertension Screening for Children Who Are Overweight or Obese: Technical Specifications (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/chronic/chipra-0232-technicalspecs.pdf
     June 02, 2025 - Hypertension Screening for Children Who Are Overweight or Obese: Technical Specifications The percentage of children aged 3 through 17 years with an outpatient care visit and a BMI ≥85th percentile who had a blood pressure percentile documented and classified as normal or abnormal during the measure…

467. Why Did It Happen? | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/cusp/videos/05h-why-did-happen/index.html
     June 01, 2018 - Why Did It Happen? CUSP Toolkit The CUSP toolkit includes training tools to make care safer by improving the foundation of how your physicians, nurses, and other clinical team members work together. These videos reinforce the material presented in each module of the CUSP toolkit. Apply CUSP To Find Out W…

468. Post-fielding Surveillance of a Guideline-based Decision Support System (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol1/Chan.pdf
     January 01, 2004 - Post-fielding Surveillance of a Guideline-based Decision Support System 331 Post-fielding Surveillance of a Guideline- based Decision Support System Albert S. Chan, Susana B. Martins, Robert W. Coleman, Hayden B. Bosworth, Eugene Z. Oddone, Michael G. Shlipak, Samson W. Tu, Mark A. Musen, Brian B. Hoffman, …

469. Prioritization Worksheet (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/pdi/c1_pdi_prioritizationworksheetinstructions.pdf
     June 02, 2025 - Ideally, if your data permit, consider only costs that occur after the adverse event occurred.

470. Prioritization Worksheet (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/c1_combo_prioritizationworksheetinstructions.pdf
     June 02, 2025 - Ideally, if your data permit, you would consider only costs that occur after the adverse event occurred

471. AHRQ’s Safety Program for Nursing Homes: On-Time Pressure Ulcer Prevention | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/pruprev/7.html
     December 01, 2017 - Limited Assistance (LA) Extensive Assistance (EA) Total Dependence (Total) Activity Did Not Occur … No setup (None) Set up only (Set up) One person (1) Two person (2) Activity Did Not Occur

472. Auditing Your Briefings and Debriefings Process: Slide Presentation | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/tools/surgery/modules/implementation/audit-briefing-slides.html
     December 01, 2017 - When did briefing occur? … When did briefing occur? Before patient entered. Before induction. Before incision.

473. Transitional Care Medication Safety: Stakeholders' Perspectives | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/reports/liability/corbett.html
     August 01, 2017 - experience at least one medication discrepancy in the transition from hospital to home, and discrepancies occur … for all classes of medicines. 9-11 Medication discrepancies that occur during the transition from hospital … institution confirms the transfer and assumption of responsibility, 15 assigning liability for errors that occur … sub-theme of our focus group findings regarding patient harm and liability was that full disclosure should occur … When errors that result in harm occur, full disclosure is the best practice.

474. AHRQ's Safety Program for Nursing Homes: On-Time Pressure Ulcer Prevention | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/pruprev/care/resources/ontime/pruprev/saworksheet.html
     December 01, 2017 - AHRQ's Safety Program for Nursing Homes: On-Time Pressure Ulcer Prevention Self-Assessment Worksheet for Pressure Ulcer Prevention The Self-Assessment Worksheet is designed to help staff review how they currently identify residents who have experienced a change in pressure ulcer risk, how they determine if ne…

475. USER GUIDE: Personal Protective Equipment (PPE) COVID-19 Observational Audit Data Tracking Tool for Use in Skilled Nursing Facilities (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/nursing-home/materials/ppe-covid19-audit-tracking-tool-userguide.pdf
     April 01, 2021 - USER GUIDE: Personal Protective Equipment (PPE) COVID-19 Observational Audit Data Tracking Tool for Use in Skilled Nursing Facilities USER GUIDE: Personal Protective Equipment (PPE) COVID-19 Observational Audit Data Tracking Tool for Use in Skilled Nursing Facilities Introduction This user guide p…

476. Antibiotic-Patient-Safety-Facilitator-Guide (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/long-term-care/antibiotic-patient-safety-facilitator-guide.docx
     June 01, 2021 - Over 90 percent of deaths associated with C. difficile infection occur in people over the age of 65,

477. Appendix A. Recommendations for Ideal Consumer Reporting Systems | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/reports/hotline/appa.html
     May 01, 2016 - Developing and Testing the Health Care Safety Hotline: A Prototype Consumer Reporting System for Patient Safety Events Appendix A. Recommendations for Ideal Consumer Reporting Systems Previous Page Next Page Table of Contents Developing and Testing the Health Care Safety Hotline: A Prototype Consume…

478. Saworksheet (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/long-term-care/resources/ontime/pruprev/saworksheet.docx
     June 02, 2025 - On-Time Pressure Ulcer Prevention Self-Assessment Worksheet for Pressure Ulcer The Self-Assessment Worksheet is designed to help staff review how they currently identify residents who have experienced a change in pressure ulcer risk, how they determine if new clinical interventions are needed, and how they determine w…

479. NICU Family Information Packet, Appendix B, Tracheostomies (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/nicu_toolkit/nicupacket-apb-trache.pdf
     June 02, 2025 - ■ Tracheo-esophageal fistula may occur as a result of posterior wall erosion.

480. Final Progress Report: Analysis of Factors Associated With Clinical Checklist Compliance (pdf file)
     www.ahrq.gov/sites/default/files/2024-05/sarcevic-report.pdf
     January 01, 2024 - input on the checklist (i.e., checking off items), because checking is sometimes delayed or doesn’t occur